Student nurse education and preparation for palliative care: A scoping review

Background The World Health Organisation and palliative care stakeholders recommend that healthcare workers are educated in palliative care. Provision of high-quality palliative care is fundamental to nursing practice. However, caring for palliative care patients and meeting family needs is challenging without appropriate knowledge and experience. Palliative care education and clinical skill development for undergraduate student nurses is a priority to ensure graduate nurses are equipped with the knowledge and skill to deliver safe and competent care. Methods A scoping review guided by Arksey and O’Malley’s framework was used to identify undergraduate student nurses’ palliative care education and preparation. A comprehensive literature search of five electronic databases and grey literature were conducted from January 2002 to December 2021. The aim was to review the empirical evidence and ascertain how undergraduate student nurses’ palliative care education is organised, facilitated, delivered and evaluated. Screening was performed independently by two reviewers against eligibility criteria with meetings to discuss included papers and form a consensus. Data was extracted and related to palliative care undergraduate student nurses’ education, educational model, methodology, key findings, and recommendations. Analysed and summarised data was mapped onto the four key review questions (educational models utilised, methods used to assess effectiveness, facilitators/barriers and gaps in the literature). Results 34 papers met the criteria for this review. The review highlights that undergraduate nursing palliative care education is more evident in high income countries. Limited and diverse published research existing in low- and middle-income countries. Educational models utilised were theoretical and experiential learning and educational process, early integration and multiple learning methods which were highlighted as facilitating factors. However, crowded curricula, lack of palliative care clinical placement expertise, difficulty providing clinical placement, timing and delivery of palliative care and difficulty responding to simulated environments (manikins) were perceived barriers. Nevertheless, palliative care education can increase knowledge, positive attitude, self-confidence and adequate preparation of undergraduate student nurses. Conclusion This review highlights that there is limited research regarding the timing and delivery of palliative care principles and practice in undergraduate student nurse education. Early integration of palliative care education impacts upon students perceived preparedness for practice and positively influences their attitudes to palliative care provision.

increase knowledge, positive attitude, self-confidence and adequate preparation of undergraduate student nurses.

Conclusion
This review highlights that there is limited research regarding the timing and delivery of palliative care principles and practice in undergraduate student nurse education. Early integration of palliative care education impacts upon students perceived preparedness for practice and positively influences their attitudes to palliative care provision.

Background
Internationally, nurse education has and continues to experience radical change in response to societal demands and professional requirements and standards. The move from medical taskoriented care to individual person and family-centred care at all stages of the lifespan is reflected in the education models that underpin the art and science of the nursing profession [1]. Focusing on palliative care is an essential part of nursing education and it is important for undergraduate student nurse to gain knowledge on palliative care to improve the overall quality of healthcare [2]. The need for palliative care education has been well documented by the World Health Organisation [3] and supported by the International Council of Nurses [4]. This need highlights that we require undergraduate student nurses to be appropriately educated to have the necessary knowledge, skills and attitudes to be able to provide palliative care across all healthcare settings upon graduation. Palliative care encompasses: "the active holistic care of individuals across all ages with serious health-related suffering due to severe illness, and especially of those near the end-of-life. It aims to improve the quality of life of patients, their families and their caregivers" [5] The elimination of serious health-related suffering includes the various health conditions or severe illness that are most likely to generate a need for palliative care. Health-related suffering is considered serious when it compromises physical, social, spiritual, and/or emotional functioning, and when it cannot be relieved with professional intervention. The goal of palliative care is to prevent and relieve suffering, and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies [5]. The alleviation of suffering is an essential function of nursing [6] and caring for a patient that requires palliative care and meeting the family's needs is challenging without appropriate knowledge [7]. Educational and clinical training requirements for undergraduate student nurses in palliative care is a phenomenon that must be considered globally. A limited but growing number of schools of nursing programmes include palliative care content in their undergraduate nursing curricula [8,9]. In addition, consensus conferences and position statements have been developed to outline and define the attitudes, knowledge and skills involved in palliative care [8,9].
While in 1967 Cicely Saunders [10] made a seminal contribution to palliative care philosophy and practice there has been a slow gradual growth and development of palliative care education. Before the 1990s, the palliative care educational needs of nurses were often overlooked in traditional nursing education settings [6]. Post 2002, there has been a great focus and emphasis for the need of palliative care education within undergraduate nursing programs. This focus and development can be linked to the priority and definition given to palliative care by the WHO [11]. Following the WHO definition in 2002 many palliative care programmes have been integrated in nursing curricula in the Western world. Palliative care educational programs that have been described typically consist of multisession training programs that incorporate attitudinal discussions and provide core knowledge and skills practice. According to the WHO policy on palliative care education, it is expected that palliative care education would be embedded in all nursing programs, but this remains unrealised in some schools of nursing [9]. Teaching palliative care within undergraduate student nurse education is seen to improve holistic, compassionate, individualised person and family-centred care [1]. Therefore, there is a need to investigate how palliative care education is embedded in undergraduate nursing curriculum, what is being taught, how it is delivered, and how undergraduate student nurses are prepared for clinical practice. Furthermore, as compassionate, competent and holistic care are at the core of nursing, knowledge of palliative care concepts is a fundamental expectation of graduating nursing students [12]. The shared theory of palliative care [13] suggests that to be competent in providing palliative care one requires sufficient knowledge and as competence influences performed interventions this translates to patient outcomes. This relationships between knowledge, competence, and patient outcomes provide a clear rationale to address the aspect of undergraduate nurses' palliative care education. While reviews have been conducted within undergraduate nurse education, they have focused on educational interventions [14], effects of simulation [15], modes of delivery/teaching strategies [16] and death education [17]. In addition, this work was pre-1994 [17] and between 1984-2012 [16], 2000-2013 [14] and 2011-2016 [15]. Thus, there is a need to map the literature to identify undergraduate student nurses' palliative care education and preparation for their practice as a registered nurse. This paper addressed this need through reviewing the literature from 2002 to 2021 representing the 20 years since the WHO 2002 definition of palliative care.

Methods
Due to the broad nature of palliative care and nursing education, a scoping review methodology was employed. This allowed for the presentation of a broad synthesis and mapping of the available evidence which is not limited by study quality or design [18]. This was an interactive process where each step was returned to and advanced during the process [19]. Consequently, utilising a scoping review assisted in identifying the current body of knowledge and existing gaps in the literature [20]. Through the systematic and transparent synthesis of the evidence, a rigorous map of the findings is presented in order to highlight the extent and nature of the literature, identify gaps and make recommendations [21,22]. The Arksey and O'Malley [18] framework was adopted for this review and the authors incorporated recent scoping review methods updates [21][22][23].
The framework utilises a five-step process: i. identifying the research question, ii. identifying relevant studies, iii. study selection, iv. plotting the data, and v. arranging, summarising and communicating the outcomes

Aim
The aim of this scoping review is to scope and map the literature to identify undergraduate student nurses' palliative care education and preparation for practice.

Identification of research question
Step one of Arksey and O'Malley's [18] framework and to meet the aim of this review, the focus is on the following questions: a. What educational models are utilised within palliative care undergraduate student nurse education?
b. What methods have been used to assess effectiveness of palliative care undergraduate student nurse education? c. What facilitators or barriers have been reported relating to the success/failure of the models of palliative care undergraduate student nurse education?
d. What gaps in the literature exist on preparation within palliative care undergraduate student nurse education?

Identification of relevant studies
In step two of Arksey and O'Malley's [18] framework to capture the broad scope of palliative care literature, a broad range of keywords and MeSH terms were used within the search [18]. The search strings were developed and agreed by the review team (AD/RR/OD). A search strategy (Table 1)

Study selection
For the third step of Arksey and O'Malley's [18] framework papers were screened in Rayyan independently by two reviewers to identify papers that meet the selection criteria (Table 2). Then, the full texts of the remaining studies were retrieved and screened against the selection criteria. Papers that met the selection criteria were included in the review.

Mapping/plotting of data
The fourth step of Arksey and O'Malley's [18] framework involved mapped the existing literature in terms of nature, characteristics and source of evidence [24]. In accordance with Arksey and O'Malley's [18] process, this stage involved extracting summaries from each paper in a data extraction table (Table 3). The data extracted from each paper pertained to the author, year, title, country, aim/focus of the paper, educational model, methodology, key findings and recommendations for undergraduate nursing palliative care education and practice. The extracted data supported the mapping of data onto the review questions and to meet the aim of the review.

Arranging, summarising and communicating the outcomes
The fifth and final stage of Arksey and O'Malley's [18] framework involved summarising and communicating the findings. A total of 34 papers was generated representing 10 countries in this scoping review. The papers are summarised and communicated under the study characteristics and the four key objectives identified in step one of the review processes. To support this process the data is mapped and charted within each reported section to present a clear and succinct summary of the data.

Results
The search of the databases and grey literature generated 18,243 results of which 18,235 originated for the five databases and 8 from grey literature searches. 7,696 duplicates were identified and removed and the remaining 10,547 papers went forward for title and abstract screening. Following title and abstract screening 10,498 papers were excluded leaving the remaining 49 papers going forward to the full-text review stage. The full text review process identified 34 papers that met the inclusion criteria and the reasons for the 15 excluded papers are reported in the PRISMA flow diagram [58] (Fig 1). This review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Scoping Reviews (PRIS-MA-ScR) (S1 Checklist) [59].     There is need for the faculty to bring in tutors who are nurses with a vaster experience and competence in palliative care to take part in the simulation sessions and the debriefings, to bring a greater knowledge of palliative care into nurse education.

Characteristics of the studies
The screening process generated thirty-four papers that met the inclusion criteria from ten countries and more than a half 56% (n = 19) were from the USA. Papers in this review  Table 4. Characteristics of the study.
Discussion/opinion n = 14 [14, 25, 27, 28, 31, 33-35, 44, 48, 50, 53, 55, 56]. https://doi.org/10.1371/journal.pone.0286678.t004 comprised of fourteen secondary data papers, thirteen quantitative papers, four qualitative papers, and three mixed-methods papers ( Table 4). The quantitative designs varied, using descriptive, observation, exploration and quasi-experimental designs. Three of the thirteen quantitative papers utilised standardised survey tools: Undergraduate Nursing Palliative Care Knowledge Survey (UNPCKS) [30], Frommelt Attitude Toward Care of the Dying Scale (FATCOD) [38] and Palliative Care Quiz for Nursing (PCQN) [49]. The four qualitative papers utilised qualitative descriptive design [26], ethnography observation [39], qualitative approach and semi-structured interview [45] and consensus-based design [51]. One of the three mixed-method papers utilised a longitudinal quantitative approach and thematic analysis to analyse qualitative data in response to open ended questions [36]. The second utilised a consultation survey via telephone and email, and a consensus-based comment and national approval process for data analysis [40]. The third paper used a 12-question survey that utilised mixed-method approach to evaluate students [46]. In addition, within the discussion/opinion papers one utilised reflective essay and assignment [46,49,55]. One utilised 2 to 3 nursing licensure examination interwoven throughout the course and a 10-question quiz with nursing licensure type items [33]. A third utilised an observer checklist in debriefing sessions [14] to evaluate learning outcome. The sample size of the quantitative papers in this review consists of the undergraduate student nurses, nursing schools/faculties, nurse educators/experts, academic leads and deans of nursing schools. Surveys included 15 national nursing faculties [29], 35 nursing schools/faculties [56] 88 nurse educators and 135 expert nurses [32], 13 academic leads and 36 deans of nursing schools [37,42]. However, other papers did not reference the number of respondents [30,48,49,53]. Student sample sizes within the quantitative papers spanned from 83 thirdyear diploma nursing students [43] to 117 third-year nursing students [38] and 1,200 undergraduate nursing students [28]. Within qualitative papers sample sizes spanning from 13 participants (7 newly trained nurses and 6 nurse tutors) [45] to 17 female junior and senior Table 5. Educational characteristics.

Conceptual Framework n = Paper
Share Theory of Palliative Care n = 1 [30].
Junior and senior baccalaureate students. Baccalaureate students.
Third-year diploma nursing students n = 1 [43]. https://doi.org/10.1371/journal.pone.0286678.t005 baccalaureate students [26] and 60 third-year nursing students in eight group sessions [39]. The mixed-methods papers had sample sizes of 336 year-three student nurses at one university [36], 37 bachelor of nursing students [46] and 8 faculties of Canadian schools of nursing [40]. The samples represented in this review were characterised by a wide range of ages, nursing programs and ethnicities with degree program students as the majority in representation. Table 6. Facilitation and delivery characteristics.
Academic nurses with contributions from other professionals n = 1 [37].
Registered nurses from the palliative care clinical setting n = 1 [42].
Online curriculum or as a hard copy n = 1 [56].
An asynchronous online format that uses discussion, reflective essay, assignments, difficult conversation, serious games, readings, short taped lectures, and multi-media content n = 1 [55].
Pedagogical approaches to encourage problem-based learning, facilitating role play and exploration of audio-visual resources (simulation) n = 1 [36].
Case studies with critical-thinking reflection, brief videos demonstrating key palliative nursing skills. N = 1 [33].
Face-to-face instruction, clinical or practicum experience online teaching, and simulation n = 1 [27].
Lecture, seminar/ small group format, role-play, videos case studies, and visits to local hospices and/or terminal patient visits and online format (simulation). N = 1 [26].
Experiential activities, including touring the local hospice care centre and retirement community n = 1 [35].
Lectures followed by small group discussion, and case study n = 1 [57].
Lectures, tutorial, and face-to-face clinical scenario, clinical practice units, and clinical placements, theoretical and experiential learning. N = 1 [53].
Four educational models were identified in this review and the conceptual or theoretical framework underpinning the palliative care education approach was evident in 5 papers and students' year of study evident in 12 papers (Table 5). Within the papers reviewed, the facilitators delivering the palliative care education were evident in 11 papers and educational delivery strategies in 22 papers (Table 6). While a broad range of educational facilitators are identified it is recommended that palliative care education should be facilitated by experts [25,32,39,57] and that experts are needed for high-fidelity simulation to enhance knowledge in palliative care and mentor students [32,44].
What methods have been used to assess effectiveness of palliative care undergraduate student nurse education?
Only 4 papers in this review highlights the evaluation of learning outcomes. The first paper utilised 2 to 3 nursing licensure examination interwoven throughout the course and a 10-question quiz with nursing licensure type items [33]. The second paper utilised an observer checklist within debriefing sessions [14]. The third paper utilised an assignment on student observation experience and case study analysis of a palliative care case study with pre and post-test [49]. The fourth paper utilised a reflective essay and assignment [55]. Within this review, palliative care education was deemed effective if it resulted in positive learning outcomes for students and 15 papers highlight effectiveness which was identified through knowledge gained, self-confidence and adequate preparedness (Table 7).

Effectiveness through knowledge gained n = Paper
Highlight opportunities for improving knowledge through palliative nursing education in academic and clinical settings n = 1 [56].
Post-test demonstrated improved knowledge of palliative care and symptom management strategies. N = 1 [49].
Both the instructor and the students felt that the course improved knowledge and was a success n = 1 [55].
Multiple methods of education delivery have shown to increase nursing students' knowledge and positive attitude about EOL care n = 1 [25].
The use of live actors and role play were effective in increasing student knowledge and self-efficacy n = 1 [44].
Students experience positive changes in knowledge and attitudes regarding EOL care n = 1 [47].
Nursing students benefit from receiving end-of-life care education in their prelicensure curriculum n = 1 [48].
Majority of the students expressed the usefulness, realistic and a good learning opportunity to handle challenging communication from patients and family members. N = 1 [39].
Students gained more knowledge in helping patients, families, and themselves in end-of-life care related issues n = 1 [26].

Effectiveness through self-confidence and adequate preparedness n = Paper
Early integration impacted student perceived preparedness and attitudes positively n = 1 [29].
EAPC 2004 document on palliative care nursing education used in many countries to foster and influence the development and preparedness of students for palliative care nursing education n = 1 [52].
Students identified growth in their practice, confidence and preparedness to deliver person-centred care in end-of-life-care n = 1 [36].
Students have primary palliative care contents in their curricula and they felt more prepared to care for patients and families, especially at the EOL n = 1 [33].
Simulation was said to adequately prepared student nurses for EOL care. Structured palliative care course influenced students' ability to be clinically competent n = 1 [38].
Educational process in a PC education has contributed to preparing students for the care of terminally ill patients n = 1 [45]. https://doi.org/10.1371/journal.pone.0286678.t007

What facilitators/barriers have been reported relating to the success/ failures of the models of palliative care undergraduate student nurse education?
Within this review nine of thirty-four papers reported a wide range of facilitators that contributed to the success of the models of palliative care undergraduate student nurse education.
The educational process was highlighted as a means of preparing students for care of the terminally ill [45]. While early integration was highlighted as enhancing and impacting undergraduate student nurses' comfort and perceived preparedness [29]. Multiple learning methods have been shown to increase knowledge and positive attitude of undergraduate student nurses towards the provision of palliative care [54] and clinical exposure to meaningful learning opportunities with patients experiencing serious life-threatening illnesses facilitates learning and enables change of attitudes [32]. A structured palliative care course [38] and the use of palliative care documents and guidelines to facilitate the success of palliative care education within the undergraduate student nurses' program were seen to influence students' ability to be clinically competent [52,56]. In the last decade, the use of simulation and analysis of scenarios has assisted to prepare students [38] and a key element within the simulation was debriefing which allowed for analysis of the dynamics occurring during the scenario [25]. Within this review, several factors acted as barriers to palliative care education were evident specifically the issue of a crowded curricula and the lack of time in the curriculum [40,53,57]. This lack of time and crowded curriculum is compounded by the lack of palliative care expertise [40] and the difficulty in providing clinical placement [57]. This results in educators and students feeling ill prepared to deliver palliative care education or feel adequately prepared for future practice [40,54]. Furthermore, there is limited research about the timing and teaching of palliative care content in undergraduate course [44] and students can find simulations using manikins difficult [47]. These factors limit undergraduate student nurses in developing the cognitive skills required for effective palliative care clinical decision making [44].

What gaps in the literature exist on preparation within palliative care undergraduate student nurse education?
In this review there is evidence of disparity and lack of research in low-middle income countries. Also, there is evidence specific to undergraduate student nurse palliative care education preparedness, barriers and implications for practice in this review. From the educational aspect, there is a lack of integration of palliative care philosophy and conceptual framework [44], crowded curricula [53], lack of nurse educators and expertise to teach palliative care within nursing faculties [40,53,57] and timing and teaching of palliative care [44] were evident from the empirical studies in this review. From a clinical practice perspective there are difficulties in providing clinical placement [57] and responding to manikins presents difficulties [47] and these barriers warrant further investigation. Hence, there is a need for further and continual research and publications in many areas of palliative care education.

Discussion
This scoping review draws together the research literature on undergraduate student nurse education and preparation for palliative care. The focus of papers identified in this review were on palliative care education (sixteen papers), end-of-life care education (eleven papers), death and dying education (four papers) and palliative and end-of-life care education (three papers). These are specific terms used for people living with life-limiting conditions that require palliative care depending on the stage of their illness or condition. The papers reviewed highlight that palliative care undergraduate nurse education is evident in both high-income countries (twenty-nine papers 85%) and in low-and middle-income countries (five papers 15%). Notwithstanding, the impact of globalisation and the effect the internet and technology has on influencing and sharing information world-wide, it is evident from this review that there is a lack of published research from low-and middle-income countries or collaborative palliative care education or research between high and low-and middle-income countries. This is important as the highest proportion of adults in need of palliative care are from low-and middle-income countries and where palliative care still developing and is primarily limited to urban areas [60].
In discussing the review question (a) What educational models are utilised within palliative care undergraduate student nurse education? This review highlights that theoretical and experiential learning go hand-in-hand in palliative care education and training [38]. This review identified five conceptual frameworks for palliative care education see Table 5. Utilising frameworks in education provides a fundamental structure to explain human behaviour towards learning [61]. Educational models are the philosophical foundation of any overall approaches and beliefs about learning, instruction and content through providing meaning and direction [62]. However, there was no evidence of integration of palliative care philosophy with the conceptual frameworks identified in this review. The use of a conceptual framework to deliver palliative care is a valuable tool for nurse educators to structure education and serves as a standard for practice because many educators/teachers continue to find values and benefits in using learning styles concept that are applicable in different situations. There is likely to be a conceptual framework which is appropriate in one situation and not in another. Therefore, there is a need to be clear which palliative care educational models and the methods are beneficial and appropriate to use. Following which it is important to investigate the conceptual frameworks appropriates and fit with palliative care philosophy to facilitate, deliver and evaluate palliative care education for undergraduate student nurses.
Discussing the review question (b) What methods have been used to assess effectiveness of palliative care undergraduate nurse education? This review highlights that palliative care educational programs facilitated by an expert multi-disciplinary team through a series of course contents that are both theoretical (classroom) and practical (skills practice in a simulated setting with anatomic models) is most effective and promote better preparation of undergraduate student nurses. For palliative care education to be effective it must result in positive learning outcomes for students [63]. Within this review effectiveness was identified through knowledge gained, self-confidence and adequate preparedness and is in line with other research [41,64]. Key within palliative care education is assessment of learning as it determines whether the learning goals are met. Well-designed assessment methods provide valuable information about student learning and identifies what was learned, how well and where they struggled [52]. The assessment methods identified in this review seem limited when compared to palliative care philosophy and educational contents. Hence, there is a need for further investigation of assessment methods that identify learning, preparedness, competence and outcomes in practice. In some incidents funding is required to determine the effectiveness of palliative care learning outcomes especially in low-and middle-income countries.
Discussing review question © What facilitators/barriers have been reported relating to the success/failure of the models of palliative care undergraduate student nurse education? It is evident that palliative care education is facilitated by a multidisciplinary team that includes nurse tutors, palliative experts, expert guest lecturers and other professional experts. Both theoretical and experiential components develop students' knowledge, skills, and attitudes. Additionally, palliative care education is being delivered using single or multiple strategies in the classroom, online and in a simulated environment/skills development laboratory, where students continue to practice key skills and demonstrate attitudes in a supervised clinical setting.
The use of blended learning that works together to develop students' knowledge, skills, and attitudes is evident in this review. Educational processes which organise and systematise patient care [45,52] and early integration [29,46] enhance and impact undergraduate student nurses' comfort and perceived preparedness. Multiple learning methods have shown to increase knowledge and positive attitude of undergraduate student nurses towards the provision of palliative care [54,65] and clinical exposure to meaningful learning opportunities facilitates learning [32,66]. Structured palliative care course influence students' ability to be clinically competent [38] and the use of palliative care documents and guidelines facilitates the success of palliative care education within the undergraduate student nurses' program [6,7]. In addition, within the last decade the use of simulation and analysis of scenarios has assisted to prepare students [38,63] and a key element within simulation is debriefing which allows for analysis of the dynamics occurring during the scenario [25,67].
What is evident from this review and the wider literature is that palliative care education requires careful planning, selection of appropriate teaching methods and learning materials, developing a course schedule and planning for student assessment [27,68]. In addition, palliative care educational programs typically require a period of study, allowing time and opportunities for students to develop essential competencies that encompass essential knowledge, skills, values, and positive attitudes [69]. Therefore, palliative care undergraduate student nurse education should start early in the program and it is crucial for nurse educators to carefully define the core knowledge that students must achieve at each level of their academic program [7,29,46]. However, to achieve the delivery of palliative care education within undergraduate nursing programs a balance has to be achieved to offset the barriers of a crowded curricula and the lack of time in the curriculum [29,40,53]. This lack of time and crowded curriculum is compounded by the lack of palliative care expertise [40]. and the difficulty in providing clinical placement [57]. These result in educators feeling ill prepared to deliver palliative care education and students feeling inadequately prepared for future practice [70]. Furthermore, this review highlights that there is limited research and agreement about the timing and teaching of palliative care content in undergraduate course [44,71] and simulation presents difficulties for students [47,72].
While a broad range of facilitators are identified within this review [25,29,39,57] it is recommend that palliative care education be facilitated by experts to enhance knowledge in palliative care and mentor students particularly for high fidelity simulation [73]. The absence of expert facilitation may limit undergraduate student nurses development of the cognitive skills required for effective palliative care clinical decision making [44,74]. Therefore, there is a need for guidance and support for both educators and students in simulation laboratory [75]. To support nurse educators responsible for designing undergraduate student nurse course contents expertise and training should be both theoretically and practically to adequately prepare students for practice.
Discussing review question (d) What gaps in the literature exist on preparation within palliative care undergraduate student nurse education? The evidence from this review highlights the disparity and lack of research in low-and -middle income countries. Research efforts build the science of nursing education through the discovery and translation of innovative evidencebased strategies. Therefore, there is a need for nurse educators, researchers and experts in the field of palliative care in low-and -middle income countries to be involved in rigorous research in the teaching-learning process and outcomes at all levels of nursing education. From the educational perspective, this review highlighted the integration of palliative care philosophy and conceptual framework, crowded curricula, the lack of nurse educators with expertise and delivery timing of palliative care education as areas for further consideration and investigation.
Given that palliative care education improves students' knowledge and increases their preparedness, further research is warranted into the correlation of palliative care philosophy and the conceptual framework to underpin undergraduate student nurse education. From a practice perspective the difficulty in providing clinical placement needs consideration and investigation. To address placement issues there is a need to consider and improve on the limited clinical placement on specialist unit, large number of students scheduled for placement at the same time and short length of placement that may negatively impact the opportunities for clinical experiences in real patients care situations. In addition, family/client involvement in palliative care education and placement provision needs to be addressed in the context of future service provision and the rights of people with life-limiting illness concerning choices that affect their lives. This needs to be considered in terms of how undergraduate student nurses will meet the professional training and educational standards requirements upon graduation. The consideration of a hub and spoke model could be one way to of bridging this issue and utilising family placement as a learning environment for students for preparing them for their future role as a registered nurse [76,77].

Limitations
While this review used precise, transparent methods based on study and reporting guidelines by Arksey and O'Malley [18] no quality appraisal was conducted as the focus of this review was to update and map the evidence. Thus, this paper only offers a descriptive account of available information and there was no patient and public involvement and there are opportunities for engagement, potentially following published guidance on stakeholder involvement in systematic reviews [78]. In addition, papers in this review were limited to only five databases which may have affected the inclusion of low-and -middle income countries and the inclusion of secondary data can be seen as both a strength and limitation.

Conclusions
This scoping review illustrates the evidence on palliative care education in preparing undergraduate student nurses for practice. The evidence identifies a wide, varied and expanding range of educational models, facilitation and delivery strategies currently in use. It is evident from this review that undergraduate student nurses require palliative care education in order to produce nurses with the graduate capabilities to deliver high-quality palliative care and to better meet the needs of an ageing population and rising consumer expectations. However, it is suggested that the integration of palliative care education contents requires focused curriculum planning to ensure clarity and cohesion in the content delivery method that is interactive and flexible involving application of different teaching strategies to minimise gaps and overlaps. While effectiveness of palliative education is important as it increases students' knowledge, improves their attitudes and prepares them to provide palliative care, future research needs to measure application to practice. Furthermore, future research needs to detail the content delivery method, assessment and evaluation method clearly.
Supporting information S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. (DOCX)